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347980-5715000U.S. Department LaborEmployment and Training AdministrationOMB Approval No. 1205-0039 Expiration Date: Dec. 31, 2018For Official Use OnlyComplaint/Apparent Violation FormComplaint No.Date ReceivedPart I. Complainant’s InformationRespondent’s Information1. Name of Complainant (Last, First, Middle Initial)4. Name of Person, Company, or Agency the Complaint is Made Against2a. Permanent Address (No., St., City, State, ZIP Code)5. Name of Employer (if different from Part I #4 above) /One-Stop Officeb. Temporary Address (if Appropriate)6. Address of Employer/One-Stop Office3a. Permanent Telephone()-b. Temporary Telephone()-7. Telephone Number of Employer/One-Stop Office()-8.Description of Complaint or Apparent Violation (If additional space is needed, use separate sheet(s) of paper and attach to this form)I CERTIFY that the information furnished is true and accurately stated to the best of my knowledge. I AUTHORIZE the disclosure ofCertification this information to other enforcement agencies for the proper investigation of my complaint. I UNDERSTAND that my identity will be kept confidential to the maximum extent possible, consistent with applicable law and a fair determination of my complaint.9. Signature of Complainant10. Date Signed // Part II. For Official Use OnlyMigrant or Seasonal Farmworker?1087755254000501562805300YesNo 184805214639100Complaint or Apparent Violation?751390981900 Complaint Apparent Violation 3. Type of Complaint or Apparent Violation (“X” Appropriate Box(es)): 90170137160003689353184690036893515049500 Employment Service Related Job Order No. Against Local Employment Service Office374015148300Against Employer3746507366000Alleged Violation of Employment Service Regulations698501333500 Employment-Related LawIssue(s) involved in Complaint or Apparent Violation (“X” Appropriate Box(es)): 1781175381000369570444500 Wage Related Housing37147512954000 17843501079500 Child Labor Pesticides1784350952500372745762000 Working Conditions Health/Safety 178435012700003727451270000 Migrant and Seasonal Disability Agricultural Worker Discrimination Protection Act (MSPA)372745635000 Discrimination Other (Specify) _____________________________5. H-2A/Criteria Employer (“X” Appropriate Box(es)):27427511239500 U.S./Domestic Worker27427510223500 H-2A Worker275170381000 Wages 273685571500 Transportation276225571500 Meals 27583210414000 Housing 27500010223500 Other _____________6a. Referrals To Other Agencies (“X” Appropriate Box(es))145224518415002406651079500WHD. U.S. DOL.OSHA U.S. D.O.L. 145224559055002406655207000EEOC Other 7. Address of Referral Agency (No., St., City, State, ZIP Code and Telephone No.)()- 13950951333500 b. Follow-Up Monthlyc. Next Follow-up Date //79692511215002857501143000YesNo82551121500 Quarterly8. Explanation of Complaint/Apparent Violation (If additional space is needed, use separate sheet of paper)-1270884960 9. Actions Taken on Complaint/Apparent Violation (If additional space is needed for multiple actions taken, use a separate paper): Action Taken By: __________________________________________________________ On: ______________________ (First and Last Name) (Date) Action Taken: 2856865184150023844251841500 10. Complaint /Apparent Violation resolved? Yes No If “No”, explain. 11. 2583567139700021482052032000Provided other One-Stop Services? Yes No If “No”, explain.12a. Name and Title of Person Receiving Complaint 12b. Office Address (No., St., City, State, ZIP Code)12c. Phone No. () - 12d.Signature12e. Date //Public Burden StatementPersons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. Obligation to reply is required to obtain or retain benefits (44 USC 5301). Public reporting burden for this collection is estimated to average 8 minutes per response, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden, to the U.S. Department of Labor, Employment and Training Administration, Office of Workforce Investment, Room C-4510, 200 Constitution Avenue, NW, Washington, DC 20210. ................
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